Medical school does not equip new doctors for the real working world, junior doctor warns

Clinician burnout and overwork are known to adversely affect patient safety and junior doctors may be particularly vulnerable, research suggests.

The UK is facing a crisis in recruitment and retention in medicine, with a recent survey by the British Medical Association reporting that 4 in 10 junior doctors will quit their roles as soon as they find another job.

Considering the immense pressure doctors are under, with their decisions having the potential to shape the course of patients’ illnesses and even their lives, is a balanced and happy life as a doctor still possible?

In a new book released today titled The Bleep Test, junior doctor Luke Austen has combined confronting first-hand experiences with research findings to argue that understanding how young doctors think and what they feel is key to looking after patients and doctors in these turbulent times.

New doctors and patient safety

There have been decades of research around the concept of ‘Black Wednesday’, the first Wednesday in August when newly qualified doctors begin life on the wards in junior positions. Studies have reported that patient safety is compromised, but overall the evidence is not conclusive.

“It’s not a good feeling to be told that after years of expensive training and dedicated study you might be a ready-made disaster for your first patients,” Austen explains. “But the reality is that even if Black Wednesday does exist, which is far from certain, the reasons behind it are likely to be complex and multifactorial. It is systems rather than individuals that truly create safety for patients.”

Austen goes on to suggest that an important part of a new doctor’s role in ensuring patient safety is being better equipped for the cognitive, psychological and emotional challenges of their work.

He explains: “Any doctor who has been through the opening months after qualifying will tell you that there is a gulf between the theory and the reality, between the title of doctor and feeling settled and safe working as one.

“But the truly difficult aspects which contribute to this divide, such as learning from making mistakes, caring for dying patients, making decisions in the throes of total exhaustion or emotionally recovering from harrowing events are not things they write about in the medical textbooks.

“At its heart is the fact that we are humans dealing with other humans and responding in very human ways. And the system often fails to recognise that.”

Civility as a tool

One of the most striking areas of research Austen points to are studies showing that the way in which doctors treat each other is safety critical.

In one high-quality study, anesthesiology residents participating in a simulated operative crisis were randomised to work with either a rude surgeon or a polite surgeon. Of those teamed up with a polite surgeon, 91% performed as expected in the crisis and passed the simulation, whereas only 64% of those working with a rude surgeon did so.

Austen explains: “Evidence from multiple studies has shown time and time again that clinicians working in teams where there is civility and mutual respect are more likely to ask questions and admit when they don’t know. Doctors should not be using valuable mental bandwidth on worrying about how to interact with a difficult colleague.”

The Bleep Test presents strategies for escalating concerns to senior doctors despite the pressures of an often-rigid medical hierarchy and argues that doctors should be trained in psychological skills to improve performance in stressful situations.

Tools for a difficult trade

The Bleep Test also provides evidence-based tools to help new doctors manage cases involving difficult conversations and patient deaths, including practical tips on delivering bad news.

These tools are put into context of Austen’s first-hand accounts of being a Covid-ICU doctor, where he witnessed staff hold the hands of patients taking their last breath in the absence of their families. He also relays anecdotes from peers who describe helping patients in desperate mental health crises with no support in place, making wrong decisions when tired, and apologising to patients when mistakes are made.

Against the backdrop of these personal tales, the book provides analysis and research-based tips with psychological tools for confronting the many and varied challenges that new doctors encounter.

In one particularly harrowing chapter, Austen considers how doctors can recover from making mistakes that may or may not have harmed a patient – including moving away from self-blame and instead trying to adopt a more pragmatic view of where personal mistakes sit in broader error chains and system failures that can let patients down.

Austen said: “The reason it’s so important we get better at this stuff is that when things go wrong for hard-working doctors whose sense of self-worth is often tied, to a greater or lesser extent, to the quality of their clinical work, the mental downward spiral can be dramatic. We have to do better at treating humans as humans.”

Understanding the difficult landscape

The Bleep Test describes the difficult landscape of the NHS and other over-stretched healthcare systems worldwide, describing UK healthcare as being ‘in a dire state’.

But he is keen to emphasise that this is not the main aim of the book, but ‘the setting of this story’.

“Of course, it matters immensely that doctors continue to campaign loudly and persistently on these issues, highlighting that problems such as underfunding and understaffing are chief amongst all patient safety concerns,” he explains. “But that is not what The Bleep Test is about.

“Yes we should keep pushing for decisive structural changes, but The Bleep Test is about looking for psychological understanding and tools to deal with the issues in front of us right now, the really hard stuff in the early years of practice.

“I certainly haven’t found all the answers, but opening a wider conversation about how new doctors think and how we look after them is a good place to start.”